Is endocervical curettage necessary? A literature review

Karen Herold

Abstract

Background: Invasive cervical cancer develops from a pre-invasive state named cervical intraepithelial neoplasia (CIN).CIN 1 represents mild dysplasia and is now classified as low-grade squamous intraepithelial lesion (LGSIL); CIN 2 and 3lesions encompass moderate-to-severe dysplasia and are now classified as high-grade squamous intraepithelial lesions(HGSILs) based on the Bethesda cervical cytology reporting system. Most LGSIL lesions resolve spontaneously, whereasHGSIL lesions are more likely to progress to invasive cervical cancer. However, HGSILs are typically detected an averageof 10 to 15 years before invasive cervical cancer. In women, the typical age range for diagnosis of invasive cancer isgreater than 40 years. High-risk Human Papilloma Virus (HRHPV) infection is required for the development of virtuallyall cervical cancer, and the time from initial HPV infection to development of cervical cancer usually exceeds 10 years.Colposcopies that are performed for abnormal papanicolaou (pap) smears of LGSIL and HRHPV can include ectocervicaland endocervical biopsies. Given the likelihood of (a) spontaneous resolution of LGSIL and HRHPV, (b) the time todevelopment of cervical cancer after initial diagnosis of HPV and (c) the improbability of invasive cervical cancerdeveloping in women less than 40 years of age, there is evidence to suggest that endocervical curettage at the time ofcolposcopy is not necessary in a subgroup of women who are at low risk of developing invasive cervical cancer. At thecurrent time, no evidence based guidelines exist about the necessity of endocervical curettage (ECC) at the time ofcolposcopy in women who are at low risk for invasive cervical cancer. Therefore, a literature review was conducted toanalyze literature as it related to ECC at the time of colposcopy in who are at low risk for invasive cervical cancer. Aparticular subgroup of women that are at low risk for development of cervical cancer are less than 35 years of age withLGSIL or HRHPV cytology, and women who are less than 35 years of age are at an even lower risk of developing invasivecervical cancer because of their more robust immune system. The purpose of the literature review was to summarizefindings about endocervical curettage at the time of colposcopy to propose a study that could be conducted to establishevidence based guidelines for ECC that could be utilized in practice.

Methods: The literature review summarizes current empirical and theoretical knowledge related to ECC at the time ofcolposcopy in women who are less than 35 years of age with LGSIL or HRHPV cytology. Concepts and keywords of theproposed literature review include: ECC-based diagnosis in each of three categories (benign, CIN 1 and CIN >1),ectocervical-based biopsy in each of three categories (benign, CIN 1 and CIN >1), LGSIL, HRHPV, colposcopy, andcervical cancer. Primary and secondary literature was examined to elucidate gaps in the literature related to evidence basedguidelines for ECC at the time of colposcopy.

Results: The literature review includes an analysis of the literature related to ECC at the time of colposcopy in womenwho were less than 35 years of age with Cervical Cytology of LGSIL or HRHPV. Additionally, the literature reviewprovides a critique of the studies that were reviewed, details gaps in the literature and enumerates the problem of noevidence based guidelines for ECC curettage at the time of colposcopy.

Conclusions: There is an absence in the literature about evidence based guidelines for performing ECC at the time ofcolposcopy in women who are less than 35 years of age with LGSIL or HRHPV; and additionally a paucity exists in theliterature about ECC at the time of colposcopy in this same subgroup of women. Therefore, the literature reviewestablishes the foundation and background for future studies that examine the need for ECC in Women less than 35 yearsof age with Cervical Cytology of LGSIL or HRHPV at the time of colposcopy.